Epsom
Dialysis and blood monitoring 14. Ms P is concerned her father did not receive adequate dialysis at Epsom. She is also concerned it did not regularly monitor his blood.
15. She says dialysis did not remove the correct amount of fluid from her father and consequently did not clean waste products from his body. She says this led to a buildup of potassium which caused his death.
16. Mr G received dialysis 14 times during his admission period of around 30 days. Epsom says on three occasions Mr G requested to come off dialysis early but received additional sessions where needed. It says Mr G’s bloods were regularly checked and there was nothing to indicate uraemia (a build-up of waste products in the blood).
17. Section 15 of GMC guidance says doctors must provide a good standard of care by adequately assessing a patient’s condition and promptly providing or arranging suitable advice, investigations or treatment where necessary.
18. UKRA guidance gives information on the management of potassium levels in dialysis patients. It recommends a blood potassium range of 4.0 to 6.0 millimoles per litre (mmol/L).
19. Our nephrologist adviser says Mr G’s dialysis was carried out with the regularity of sessions they would expect to see. Where sessions appear to have been missed, staff arranged additional sessions to make up for this.
20. For example, Mr G received an extra dialysis session on admission, which made up for the lost dialysis session the day before and he received an extra session on 16 April because of fluid build-up (an accumulation of more fluid in the body than it can handle). Following this, Mr G continued with regular dialysis for the remainder of his admission.
21. Ms P says her father did not receive dialysis in-keeping with his prescription, which was for 3.5 hours during his admission period.
22. We can see the time of the delivered dialysis was generally below the prescribed 3.5 hours, but our nephrologist adviser explained there is no evidence this caused harm and Mr G’s blood results support this.
23. Staff took Mr G’s bloods on 14 occasions during his admission which our nephrologist adviser says is evidence he was being monitored appropriately. By comparison, a patient receiving dialysis in an outpatient capacity would receive blood tests once a month.
24. Those blood samples show urea and creatinine were at acceptable levels. Potassium, which needs to be kept to a tight range to avoid harm, was also at acceptable levels throughout.
25. For example, Mr G’s potassium levels were 4.4 to 5.8 on most of the occasions it was measured. There was one higher level of 6.4 on 21 April, but subsequent potassium levels were below 6. This is broadly in line with UKRA guidance.
26. We can see no evidence to indicate Epsom mishandled Mr G’s dialysis or failed to appropriately monitor his blood. Its actions therefore appear be in line with both UKRA guidance and GMC guidance.
27. We understand Ms P is very concerned about the dialysis her father received. We recognise she strongly believes poor management of his dialysis at Epsom contributed to his death following his transfer to Croydon (which we will discuss later in this statement). We hope our statement provides Ms P with some reassurance around the dialysis her father received at Epsom.
Communication 28. Ms P says she visited her father and found him very distressed as he had not been given any information about his diagnosis or treatment.
29. Epsom says its doctors did discuss test results and treatment options with Mr G. It says this included regular discussions around pain relief, discharge planning and his dialysis.
30. Sections 31 and 32 of GMC guidance says doctors must listen to patients, take account of their views and give them the information they want or need to know.
31. In reviewing Mr G’s medical records, we have seen a number of entries where doctors did discuss various aspects of care with him.
32. For example, on 14 April, we can see a renal consultant reviewed Mr G and discussed his test results and his treatment plan. The next day, another doctor discussed blood results with him. This appears to have been discussed alongside test results, including a computerised tomography (CT) scan and echocardiogram which reviewed his aortic stenosis.
33. We can see Ms P raised concerns on 20 April that her father was frustrated no one was updating him. Following this, doctors reviewed him the next day and discussed his condition and treatment.
34. We recognise we cannot comment on the quality of the discussions staff had with Mr G as we were not present. We can see doctors periodically discussed Mr G’s treatment with him and there is no indication they failed to share important information with him during these discussions.
35. We understand Ms P is concerned her father was not given an appropriate level of information during his admission period. Having reviewed all the available evidence, we are satisfied, overall, that doctors shared information with Mr G about his care in line with GMC guidance.
Food and drink 36. Ms P is concerned her father did not receive enough food and drink during his admission.
37. Epsom says Mr G was assessed as being at low risk for nutritional concern and therefore did not require specific input from a dietician. It also says Mr G was eating and drinking independently and there were no concerns around this.
38. NMC guidance, part 1, says nurses must deliver the fundamentals of care effectively. It also says any treatment, assistance or care must be delivered without undue delay.
39. Our nurse adviser says it is important to note food and fluid charts would not be used for every patient. Malnutrition Universal Screening Charts (MUST) or Validity of a Renal Inpatient Nutrition Screening Tool (iNUT) are used to assess whether a patient may be at risk of malnutrition if their food and fluid intake is not closely monitored.
40. When a patient is assessed as high-risk using MUST or iNUT, their food and fluid will be closely monitored by using food and fluid charts. If they are low risk, such charts will not be used.
41. Mr G was a renal patient, and we can see he correctly received an iNUT assessment which indicated he was at low risk of malnutrition. For this reason, staff did not need to complete food and fluid charts.
42. Mr G’s weight on 8 April was 104.5kg and was 104.7kg on 7 May, prior to his transfer to Croydon. Alongside this, we can see Mr G was, overall, recorded to have been eating and drinking well throughout his admission.
43. We therefore see no indication of a failing in how staff managed Mr G’s food and fluid intake, and it appears to have been handled in line with NMC guidance.
Mr G’s low mood 44. Ms P says her father became increasingly distressed and hopeless during his admission. She says no effort was made to treat his mental anguish.
45. Epsom acknowledges Mr G was in low mood some of the time. It says it is ‘standard practice’ to offer patients counselling where needed, but there is no evidence to indicate it did so in this case. Epsom offered apology that no counselling was offered to Mr G.
46. Section 3 of NMC guidance says nurses have the responsibility to maintain a patient’s physical, social and psychological needs.
47. On 20 April we can see Ms P contacted staff to say she was concerned about her father as he appeared depressed and frustrated. This appears to have been conveyed to ward staff and a nurse subsequently noted Mr G appeared in low mood.
48. There does not appear to be any further mention of Mr G’s low mood until eight days later on 28 April where he is noted as appearing in ‘very low mood’.
49. However, later that same day a nurse asked if Mr G had any concerns and was told he did not. They noted he appeared in ‘good mood’.
50. Our nurse adviser says Mr G’s mood appeared to fluctuate throughout his admission but there was nothing which jumps out to indicate he was depressed or required psychological assessment or that staff missed anything in this respect. We have seen evidence nursing staff did check in with Mr G regularly during his admission.
51. We recognise low mood can lead to low energy and being less engaged. It can, therefore, inhibit a patient’s recovery. In looking at the records, there is nothing to indicate low mood inhibited Mr G from being engaged in his recovery. For example, there is nothing to suggest any low mood inhibited physiotherapy related activities.
52. We acknowledge Epsom provided an apology during the complaints process because it felt it should have offered Mr G counselling. While we are pleased Epsom took Ms P’s complaint seriously and considered where its service may have fallen short, we are not persuaded its actions fall outside of what is expected under NMC guidance.
53. For the reasons set out above, we decided to take no further action in this element of Ms P’s complaint.
Falls 54. Ms P says her father fell twice during his admission and one of those falls could have been avoided had Epsom correctly raised the rails on his bed as she suggested.
55. Ms P says she was already concerned about her father’s wellbeing and learning of the falls caused additional upset and distress at an already difficult time.
56. Epsom says Mr G suffered two falls. The first was a fall from bed and in the second, he was ‘seen to slide from his chair and nursing staff were able to assist him to the floor to prevent him from coming to harm’.
57. Epsom agrees it made mistakes in how it handled Mr G’s risk assessments and says the incidents were investigated via its risk assessment system to identify learning. It says both incidents resulted in no harm to Mr G.
58. It is important to set out that Mr G’s first fall, in which he fell from bed, is very different to the second fall, which appears to have been a controlled fall from his chair assisted by staff. Our consideration will therefore focus upon the first fall.
59. NICE guidance, part 1.2.1 says risk assessments should be carried out promptly. Our nurse adviser says this means any falls risk assessments should be carried out upon, or shortly after admission.
60. Our Principles say public bodies should acknowledge when they make mistakes, explain what went wrong and attempt to put right what went wrong quickly and effectively.
61. We have found no evidence the Trust carried out falls risk assessments on 8 April when Mr G was admitted. Mr G had his first first falls risk assessment after he fell from bed on 12 April. We can see further risk assessments were carried out on 16 April which scored Mr G ‘1A’. This score indicated Mr G required bed rails.
62. There is an indication of a failing here. Mr G was not risk assessed upon admission in line with NICE guidance. Risk assessments only took place following his fall from bed and identified at that stage he needed bed rails.
63. We can see Epsom acknowledged it should have carried out a falls risk assessment upon admission. It says it discussed this with ward staff during a staff meeting on 29 June in which staff were reminded of the importance of prompt and continuous falls risk assessments.
64. We are satisfied Mr G was unhurt by his fall from bed on 12 April. We appreciate this likely had an emotional impact upon Ms P, as set out in paragraph 57. We are pleased Epsom took Ms P’s complaint seriously and reminded staff of the correct process.
65. Having carefully considered this part of the complaint, we are satisfied Epsom’s actions are proportionate to help put things right. We also think Epsom should apologise to Ms P as one was not provided during the complaints process.
66. We contacted Epsom, and it agreed to provide Ms P with an apology for any distress caused by these events.
67. Having carefully considered this, we think the service improvements already put in place by Epsom, alongside its agreement to provide an apology is proportionate to put right what went wrong. This approach is in line with our Principles.
68. We have therefore decided to take no further action in this element of Ms P’s complaint. Epsom will be in touch with her shortly to provide its written apology.
Croydon
Handover of care 69. Ms P is concerned Croydon did not receive a detailed handover from Epsom, and her father’s care may have suffered as a result.
70. We understand this element of the complaint was handled by Croydon but also relates to Epsom’s actions as it had previously treated Mr G and was now handing over his care. It is therefore the joint responsibility of both Epsom and Croydon to ensure the appropriate information was both provided, and received, when transferring a patient.
71. Croydon says its medical team received a detailed handover from Epsom including Mr G’s medical history. It says it was made aware of his ‘complex multiple medical issues’ which included possible infection, his aortic stenosis and his longstanding dialysis needs.
72. Part 44 of GMC guidance says doctors must contribute to the safe transfer of patients between healthcare providers. It says doctors must share all relevant information with colleagues involved in the patient’s care.
73. We can see doctors at Epsom discussed Mr G’s transfer with colleagues at Croydon on 30 April in preparation for the transfer of care. Unfortunately, owing to a lack of bedspace at Croydon, the transfer was delayed. The transfer took place on 7 May.
74. Mr G was transferred one week after the verbal medical handover took place, but our physician adviser says this would not have been an issue.
75. While the medical records do not elaborate on what was discussed during the verbal handover (our physician adviser says this is typically not detailed in the notes) Mr G did receive a discharge summary from Epsom setting out all relevant clinical information, and this was available for Croydon’s doctors to examine.
76. We can see this information was provided and examined because Croydon’s discharge planning (prior to Mr G’s deterioration and death) listed Epsom’s clinical findings and his past medical history.
77. For the reasons set out above, we are satisfied Croydon (and Epsom) acted in line with GMC guidance in passing on, and taking note of, all the relevant clinical information as part of Mr G’s transfer of care on 7 May. There is nothing to indicate this handover negatively impacted upon Mr G’s care.
Insulin and blood glucose levels
78. Ms P is concerned her father did not receive his insulin at the correct times as his blood sugar was very low on 9 May. Insulin is used to manage blood sugar levels in people with diabetes.
79. Croydon says Mr P’s blood sugar was correctly managed using lantus (long-acting insulin) once daily at night.
80. Section 15 of GMC guidance set out in paragraph 19 is relevant here.
81. Mr G’s blood results show good glycaemic control (the body’s management of blood sugar) during his admission. From 9 May, for example, we note his blood sugar ranged from 8.6 to 10.
82. Acceptable blood sugar levels can vary from patient to patient. Our physician adviser reviewed Mr G’s blood sugar levels and noted there were no readings which gave any cause for concern during his admission.
83. Our physician adviser also says Croydon’s use of lantus is appropriate. Lantus is long-acting insulin and will keep blood sugar levels stable for a long period of time. This contrasts with shorter acting insulins which generally help to counteract rises in blood sugar after eating.
84. We acknowledge Ms P’s view that her father’s blood sugars were usually above 10 and that anything below this was abnormal. Having reviewed Mr G’s medical records, however, we are satisfied his blood sugars were at acceptable levels and were managed in line with GMC guidance.
Dialysis 85. Ms P is concerned her father did not receive dialysis upon transfer to Croydon. She says her father required regular dialysis and if dialysis was not carried out, waste products could build up in his blood and cause harm.
86. Croydon says its renal doctor planned for Mr G to have dialysis on 10 May. Sadly, Mr G deteriorated that same day and died.
87. GMC guidance and UKRA guidance set out in paragraphs 19 and 20 are also relevant here.
88. We can see Mr G received dialysis at Epsom on 7 May prior to his transfer to Croydon.
89. Our nephrologist adviser says Mr G’s Croydon admission records note what appears to be mild to moderate fluid build-up. They say this level of excess fluid is common in unwell hospital dialysis patients and it does not appear to have been causing excess strain on Mr P’s heart or lungs.
90. Our nephrologist adviser adds that blood tests on 8 May showed haemoglobin levels (the substance in red blood cells which transports oxygen) alongside blood waste products (urea, creatinine and potassium) were all at levels in keeping with a typical dialysis patient who has been unwell in hospital and may have ongoing inflammation or infection.
91. As such, we could not identify any areas of concern at this point.
92. If Mr G had kept to his previous dialysis pattern at Epsom (Tuesday to Thursday to Saturday with a few days break, which is standard practice for dialysis patients) his next dialysis session would have been on Tuesday 10 May.
93. We can see a member of staff called Croydon’s dialysis unit on 9 May to arrange a dialysis session for Mr G at 7am on 10 May.
94. Blood tests on 9 May reflect an increase in blood waste products but Mr G’s urea, creatinine and potassium (which was at 5.9) are all at levels in keeping with an ill inpatient on dialysis. Based on this, our nephrologist adviser says there was no reason to bring dialysis forward.
95. Sadly, Mr G suffered cardiac arrest and died at around 2am on 10 May.
96. We understand Ms P is concerned about her father’s potassium levels on 10 May and whether it caused his cardiac arrest. She says her father had a pacemaker fitted (a pacemaker is a device which regulates heartbeats electrically), so his cardiac arrest must have been caused by the high potassium level in his blood.
97. Croydon says Mr G’s potassium levels reached 6.6, but this was something he had previously tolerated, so was not considered to be the cause of his cardiac arrest.
98. We can see blood gas samples taken during Mr G’s attempted resuscitation show a potassium level of 6.6, followed by a further reading of 6.5.
99. Our nephrologist adviser says these results should be taken in the context of Mr G’s attempted resuscitation and death with very acidic blood (low pH). They say this is relevant because Mr G’s potassium levels may have been falsely elevated by the acid levels in his blood at this time and the way in which a blood gas sample is taken (a shaken sample can release more potassium).
100. Although Mr G’s potassium levels were high, our nephrologist adviser does not consider this to be the cause of his cardiac arrest for the reasons set out above and because Mr G had tolerated potassium levels over six previously.
101. We recognise Ms P strongly believes her father’s cardiac arrest was caused by a build-up of potassium in his blood. She points to the coroner’s report which recorded fibrinous pericarditis (Inflammation of the thin membrane around heart), and that the coroner noted uraemia can cause this condition.
102. We reviewed the coroner’s report and found it did not find Mr G was suffering from uraemia. The coroner noted several other conditions which could have caused Mr G’s fibrinous pericarditis but said due not having Mr G’s medical records or his blood results, it was not possible to state whether any if these were applicable in his case.
103. The coroner’s report does not conflict with what our nephrologist adviser found and what we have set out in this statement. While we take Ms P’s point around the presence of fibrinous pericarditis, there is no evidence to suggest this was caused by uraemia which, in turn, was caused by poor dialysis.
104. Having carefully considered the available evidence, we can find no indication of a failing in how Croydon managed Mr G’s dialysis. It appears to have provided dialysis in line with both UKRA guidance and GMC guidance.
105. We understand this decision will likely be very upsetting for Ms P, but we hope we have provided some reassurance around her father’s dialysis and that we have carefully considered all the available evidence before reaching our decision.
Mr G’s phone 106. Ms P says she received a call from her father’s phone and assumed it was him. She says it was in fact a staff member who had called to tell her that her father had died.
107. She says she was shocked and distressed to receive such upsetting information using her father’s phone.
108. Croydon says it is not normal practice for staff to use a patient’s mobile phone to call their next of kin and it suspects a temporary ‘bank member’ of nursing staff who no longer works for Croydon was responsible. It apologised for what happened and for the pain and upset it caused.
109. It says learning from this incident was shared with staff to ensure they followed the correct protocols in terms of patient property.
110. It also says next of kin details are now easily accessible on the patient’s medical records and on nursing hand-over sheets. We understand this will ensure no staff member should feel the need to access a patient’s property to obtain contact details.
111. The nurse’s actions do not appear to be in line with section 5.5 of NMC guidance which says patient information should be shared with family members sensitively.
112. We asked Croydon to provide us with audits of its improvements to evidence they have been adhered to.
113. Croydon provided us with audit sheets for 2023 and 2024. Having reviewed those audit sheets, we are satisfied it shows Croydon took appropriate action to avoid such problems reoccurring and is continuing to monitor it.
114. We were sorry to hear about Ms P’s experience and the additional upset this will have caused at an already distressing time.
115. We can see Croydon acknowledged it made a mistake and took action to prevent it from happening again. It also provided appropriate apology during the complaints process.
116. Having carefully balanced these events, we think both Croydon’s apology and the service improvements it has already put in place are proportionate to put right what went wrong and are in line with our principles (set out at paragraph 62). We have therefore decided to take no further action in this part of Ms P’s complaint.
117. We appreciate the pain and distress which was likely caused to Ms P by receiving such distressing news on her father’s phone. We hope she is reassured that Croydon has since improved its service which should prevent an incident like this from happening again.
118. We have decided to take no further action in Ms P’s complaint for the reasons set out in our statement.
119. We recognise Ms P continues to experience upset and distress around the loss of her father and the way in which his care was handled at both Epsom and Croydon.
120. We appreciate our primary investigation cannot change what happened or take away her pain. We thank Ms P for taking the time to bring her complaint to our Office and sincerely hope our statement addresses the concerns she has about what happened and provides some reassurance around the care her father received.